JudyAnn Bigby

Disparities across the breast cancer continuum

Objective: We performed a structured review of the literature to identify areas of greater and lesser knowledge of the nature of disparities across the breast cancer continuum from risk and prevention to treatment and mortality.Methods: We searched OvidMedline and PubMed to identify published studies from January 1990 to March 2004 that address disparities in breast cancer. We read the abstracts of the identified articles and then reviewed the articles if they were in English, were limited to American populations, limited to women, and described quantitative outcomes. We designated the articles as addressing one or more disparities across one or more of the domains of the breast cancer continuum.Results: Substantial research exists on racial disparities in breast cancer screening, diagnosis, treatment, and survival. Disparities in screening and treatment exist across other domains of disparities including age, insurance status, and socioeconomic position. Several gaps were identified including how factors interact.Conclusion: A structured review of breast cancer disparities suggests that research in other domains of social inequality and levels of the cancer continuum may uncover further disparities. A multidisciplinary and multi-pronged approach is needed to translate the knowledge from existing research into interventions to reduce or eliminate disparities.

Assessing the preventability of emergency hospital admissions: a method for evaluating the quality of medical care in a primary care facility

The quality of primary medical care was assessed by studying the events leading to 686 emergency admissions of patients from our hospital-based primary care practice. Independent physician reviewers determined that 59 (9 percent) of the admissions were potentially preventable; 40 were due to iatrogenic factors including inadequate follow-up and adverse drug reactions, 12 were due to lack of patient compliance, and seven were due to both iatrogenesis and noncompliance. Adverse drug reactions were the most common cause of iatrogenesis, and warfarin was the drug that most commonly caused an adverse reaction. Inadequate follow-up of abnormal physical findings, symptoms, and laboratory test results was also important. Patients with preventable admissions had more medical diagnoses (4.9 versus 4.1, p less than 0.01), were prescribed more medications (4.5 versus 3.7, p less than 0.01), and were older (66.5 years versus 60.2 years, p less than 0.01) than patients whose admissions were not preventable. It is concluded that a small percentage of emergency hospitalizations may be preventable and that systematic review of emergency hospitalizations may provide a means of measuring the quality of primary medical care.

Impact of race on the professional lives of physicians of African descent.

Diversifying the physician workforce is a national priority (1). However, despite efforts to increase the numbers of minority physicians (26), people of African descent represent only 2% to 3% of practicing physicians in the United States (7). Furthermore, this proportion has not changed substantially during the past 30 years (1, 8). Understanding how race influences the work experiences of physicians of African descent is fundamental to developing effective strategies to recruit and retain a diverse physician workforce. Evidence indicates that physicians of African descent face considerable challenges because of their race. Most minority physicians report that they have experienced racial or ethnic discrimination at work (912), and rates of reported racial discrimination are highest among physicians of African descent (10, 11). Studies of physicians in academic medicine show that medical school faculty of African descent have lower job satisfaction (11, 13) and are promoted less frequently (14, 15) than their nonminority counterparts who have similar productivity and similar academic accomplishments. Although this evidence documents the substantial prevalence of race-related challenges for physicians, qualitative information to understand how physicians of African descent experience race in the workplace is lacking. The design of interventions to successfully attract, integrate, and support a diverse workforce depends on a clear understanding of the role of race in the professional lives of physicians. Therefore, we sought to characterize these experiences through in-depth interviews with physicians of African descent practicing in academic and nonacademic settings and across a range of clinical specialties. We used qualitative data analysis techniques to identify the unifying and recurrent themes that show how race shapes the work experiences of physicians of African descent. Methods Study Design and Sample We conducted a qualitative study by using in-depth interviews with 25 physicians who identified themselves as being of African descent and who practiced in 1 of the 6 New England states. People of African descent include Africans and African Americans and those from other regions of the African diaspora, such as African Caribbeans. We did not interview physicians of other races because we only studied how physicians of African descent experience race at work. We chose a qualitative approach to explore a complex and potentially sensitive topic involving social and cultural interactions that are difficult to measure quantitatively (16, 17). On the basis of principles of grounded qualitative research, we aimed to generate hypotheses from the data as opposed to testing prespecified hypotheses (1620). We recruited an information-rich and purposeful sample (16, 17) of physicians of African descent from the 6 New England states. We excluded physicians in training. We identified potential participants from the membership roster of the New England Medical Society (an organization of minority physicians); the Web-based African American physician locator, which uses membership data from the National Medical Association; community-based organizations; and regional academic institutions. We randomly selected physicians from among those who responded to an invitation to participate within the first 2 weeks. In addition, using the snowball technique (16, 17), we asked study participants to provide names of other physicians of African descent in the region. All invited physicians agreed to participate. We interviewed practicing physicians until no new themes emerged from successive interviews, that is, until thematic saturation was achieved. The research protocol was approved by the Human Investigation Committee of the Yale University School of Medicine, New Haven, Connecticut. We obtained verbal informed consent from participants. Data Collection One of the researchers conducted in-person, in-depth interviews (21). Interviews were racially concordant and consisted of the interviewer and an individual participant. The average length of the recorded interview was 40 minutes. Professional transcriptionists transcribed interviews, and the interviewer reviewed the transcriptions to ensure accuracy. Interviews (Figure) began with a broad question: How do you think race influences your experiences at work? Specific questions addressed negative and positive work experiences attributed to race and the influence of race on the physicians career trajectories. Probes were used to encourage participants to clarify and elaborate on their statements as necessary. Figure. Standard interview guide. Statistical Analysis In the first stage of analysis, codes were created and defined as concepts that emerged from the data in an inductive fashion (21, 22). The coding team independently coded transcripts line by line and, as needed, met as a group to reach consensus. Using the constant comparative method of qualitative analysis (21, 22), we compared coded text to identify novel themes and expand existing themes, refining the codes as appropriate until we reached a final coding structure that comprehensively defined all codes (22, 23). Using this final coding structure, the researchers independently coded 3 previously uncoded transcripts. The calculated intercoder agreement was 80%, which is considered acceptable by qualitative research standards (24). One researcher then used the final code structure to recode all transcripts. We used qualitative analysis software (ATLAS.ti 5.0, Scientific Software Development, Berlin, Germany) to facilitate data organization and retrieval (25). As recommended by experts in qualitative analysis (23), participants reviewed a summary of the data and endorsed the content of the themes after the analysis was complete. Role of the Funding Sources The funding sources had no role in the design, analysis, or reporting of the study or in the design to submit the manuscript for publication. Results Physician participants represented a range of practice settings, specialties, and ages (Table). Five recurrent themes characterized how physicians of African descent experienced race in the health care workplace: 1) awareness of race permeates the experience of physicians of African descent in the health care workplace; 2) race-related experiences shape interpersonal interactions and define the institutional climate; 3) responses to perceived racism at work vary along a spectrum from minimization to confrontation; 4) the health care workplace is often silent on issues of race; and 5) these experiences can result in what we term racial fatigue, with personal and professional consequences for physicians. We provide verbatim quotations to illustrate each theme. Table. Characteristics of the 25 Study Participants* Awareness of Race Permeates the Experience of Physicians of African Descent in the Health Care Workplace All participants described race as pervading their identity and experiences in the health care workplace. Physicians offered several examples of how race often influenced their professional experiences. A general surgeon at an academic institution commented on his perception of how he is viewed by others at work: I think race permeates every aspect of my job; so when I walk onto a ward or on the floor, Im a black guy before Im the doctor. Im still a black guy before Im the guy in charge, before Im the attending of record, so that permeates everything. Participants also described the importance of race in influencing their self-view in the workplace. For some physicians, the influence of race on self-view was shaped by the participants country of origin. A general internist at an academic institution who is from the United States reflected: I am your classic African American. What I mean by that is that I think about race all the time. At least 50 times a day. I wouldnt say race has influenced me. It defines me. It defines what I do. [It defines] everything. In contrast, a physician practicing family medicine at an academic institution who immigrated to the United States as an undergraduate student stated: Race influences the personalities of Americans much more deeply than for Africans or other people not born in this country. As an African, my primary mode of identification is not race. Still, most people [in this country] see me and for them its race. [S]o it definitely affects what I do. Its probably the most important thing. Regardless of where they were from, participants reported constant awareness of their racial minority status in the workplace. However, physicians sometimes tried to take the focus off of race in the workplace. An internal medicine subspecialist working at a hospital-based practice reflected: Growing up as I did in this country, however, I am perpetually aware of race with every individual that I meet, my cofaculty, my patients, the other health care workers here, but I think I have tried to take an approach that to whatever extent possible, I try to take race out of the equation. Regardless of whether participants focused on the influence of race at work, they reflected on the intersection of authority and race in their work lives. A pediatrician at an academic institution said the following: It is hard being a physician of color because you have the issue of race and the issue of power. When you are a physician, you have a power position that other people dont have, whether they are of the same race or different race or whatever. So, sometimes it is tricky. Are you annoyed that I am in the position that I am in or [are you] annoyed about my position because of my race? Race-Related Experiences Shape Interpersonal Interactions and Define the Institutional Climate Race influenced the professional lives of all participants. They described the effect of race on their relationships with patients, staff, and colleagues and its effect on their roles in the broader health care institutional envi

Addressing Social Determinants of Health to Improve Access to Early Breast Cancer Detection: Results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women's Health Demonstration Project

BACKGROUND The Boston Racial and Ethnic Approaches to Community Health (REACH) 2010 Breast and Cervical Cancer Coalition developed a case management intervention for women of African descent to identify and reduce medical and social obstacles to breast cancer screening and following up abnormal results. METHODS We targeted black women at high risk for inadequate cancer screening and follow-up as evidenced by a prior pattern of missed clinic appointments and frequent urgent care use. Case managers provided referrals to address patient-identified social concerns (e.g., transportation, housing, language barriers), as well as navigation to prompt screening and follow-up of abnormal tests. We recruited 437 black women aged 40-75, who received care at participating primary care sites. The study was conducted as a prospective cohort study rather than as a controlled trial and evaluated intervention effects on mammography uptake and longitudinal screening rates via logistic regression and timely follow-up of abnormal tests via Cox proportional hazards models. RESULTS A significant increase in screening uptake was found (OR 1.53, 95% CI 1.13-2.08). Housing concerns (p < 0.05) and lacking a regular provider (p < 0.01) predicted poor mammography uptake. Years of participation in the intervention increased odds of obtaining recommended screening by 20% (OR 1.20, 95% CI 1.02-1.40), but this effect was attenuated by covariates (p = 0.53). Timely follow-up for abnormal results was achieved by most women (85%) but could not be attributed to the intervention (HR 0.95, 95% CI 0.50-1.80). CONCLUSIONS Case management was successful at promoting mammography screening uptake, although no change in longitudinal patterns was found. Housing concerns and lacking a regular provider should be addressed to promote mammography uptake. Future research should provide social assessment and address social obstacles in a randomized controlled setting to confirm the efficacy of social determinant approaches to improve mammography use.

Evaluation of a faculty development program in substance abuse education.

AbstractObjective: To determine whether a faculty development program was effective in increasing clinical skills and the amount of substance abuse teaching of individual general medical faculty. Design: Program participants were evaluated with a structured assessment before and several months after participating in a faculty development program in substance abuse education. Participants: Eighty percent were general internal medicine faculty, who on average devoted 25% of their time to teaching. The remainder of the participants were family medicine, psychiatry, or other internal medicine faculty and nonphysician teachers. Intervention: The participants attended a learner-centered, largely experiential faculty development program in substance abuse education to improve their clinical and teaching skills relevant to substance abuse among patients in the general medical setting. Measurements and main results: Eighty-six percent of the participants completed the evaluation. The participants reported increased confidence in their clinical skills in recognizing substance abuse, presenting the problem to the patient, and referring the patient for treatment. The participants also reported improved attitudes toward patients and increased teaching about the management of the primary problem of substance abuse, but not at the expense of teaching about medical complications. Conclusions: Clinically oriented, interactive faculty development courses in substance abuse education can contribute to increased confidence in clinical skills in substance abuse as well as teaching about substance abuse.

Women and Alcohol Abuse in Primary Care: Identification and Intervention

Female problem drinkers are less likely than men to be identified in the primary care setting. The authors studied 24 adult women attending a general, internal medicine clinic to assess the efficiency of self-reports of alcohol consumption when compared with physician identification and other measures and the impact of a brief intervention on alcohol consumption. Despite the high rate of lifetime (79%) and current (67%) alcohol diagnoses, no patient was in alcohol treatment. Physician identification of alcohol problems was least sensitive but most specific, when compared with other measures. Brief intervention, as offered in this study, did not appear to modify alcohol consumption.

Impact of participation in a community-based intimate partner violence prevention program on medical students: A multi-center study

BackgroundPhysicians are generally poorly trained to recognize, treat or refer adolescents at risk for intimate partner violence (IPV). Participation in community programs may improve medical students’ knowledge, skills, and attitudes about IPV prevention.ObjectiveTo determine whether the experience of serving as educators in a community-based adolescent IPV prevention program improves medical students’ knowledge, skills, and attitudes toward victims of IPV, beyond that of didactic training.ParticipantsOne hundred and seventeen students attending 4 medical schools.DesignStudents were randomly assigned to didactic training in adolescent IPV prevention with or without participation as educators in a community-based adolescent IPV prevention program. Students assigned to didactic training alone served as community educators after the study was completed.MeasurementKnowledge, self-assessment of skills and attitudes about intimate partner violence and future plans to pursue outreach work.ResultsThe baseline mean knowledge score of 10.25 improved to 21.64 after didactic training (p ≤ .001). Medical students in the “didactic plus outreach” group demonstrated higher levels of confidence in their ability to address issues of intimate partner violence, (mean = 41.91) than did students in the “didactic only” group (mean = 38.94) after controlling for initial levels of confidence (p ≤ .002).ConclusionsExperience as educators in a community-based program to prevent adolescent IPV improved medical students’ confidence and attitudes in recognizing and taking action in situations of adolescent IPV, whereas participation in didactic training alone significantly improved students’ knowledge.

The Challenges of Understanding and Eliminating Racial and Ethnic Disparities in Health

Former Surgeon General Dr. David Satcher alerted the nation to the gross disparities in health that exist in this country and pushed for elimination of disparities as a high-profile objective for the Clinton administration.1 His use of the bully pulpit to alert this nation, viewed by some as having the best health care in the world, that disparities in health care access, treatment, quality of care, and health outcomes exist between Americans from racial and ethnic minority groups and white Americans will influence research and policy in this nation for years to come. Current efforts to address disparities by the Department of Health and Human Services often focus on individual behaviors such as diet, exercise, and tobacco use. However, the evidence about why health disparities exist suggests complicated interactions between national and local health policies, institutional policies and procedures, individual provider behavior, and personal health–related behaviors in the larger context of economic and educational inequalities and opportunities and other social determinants of health. In all likelihood disparities in health between African Americans, Latinos, American Indians, Alaska Natives, and other Americans from racial and ethnic minority groups and white Americans will continue to exist unless we as a nation address the root causes of disparities from every dimension.

Substance abuse and AIDS: a faculty development program for primary care providers.

The authors implemented a three-day faculty development program on substance abuse and AIDS for primary care faculty. Objectives included: 1) increased knowledge concerning clinical issues; 2) skill development focusing on provider-patient interactions; and 3) the development of educational approaches for teaching about substance abuse and AIDS. Teaching formats included didactic (40%) and experiential (60%) sessions emphasizing role playing with patients affected by both substance abuse and HIV infection. Four courses have been given to 109 participants, who have rated the course highly in terms of its educational quality (4.4/5.0) and usefulness (4.2/5.0). At six-month follow-up, 75% of the participants reported enhanced teaching as a result of this faculty development program.

Mammography use among black women: the role of electronic medical records.

BACKGROUND AND AIMS Accurately documenting mammography use is essential to assess quality of care for early breast cancer detection in underserved populations. Self-reports and medical record reports frequently result in different accounts of whether a mammogram was performed. We hypothesize that electronic medical records (EMRs) provide more accurate documentation of mammography use than paper records, as evidenced by the level of agreement between womens self-reported mammography use and mammography use documented in medical records. METHODS Black women aged 40-75 were surveyed in six primary care sites in Boston, Massachusetts (n = 411). Survey data assessed self-reported mammography prevalence within 2 years of study entry. Corresponding medical record data were collected at each site. Positive predictive value (PPV) of self-report and kappa statistics compared data agreement among sites with and without EMRs. Logistic regression estimated effects of site and patient characteristics on agreement between data sources. RESULTS Medical records estimated a lower prevalence of mammography use (58%) than self-report (76%). However, self-report and medical record estimates were more similar in sites with EMRs. PPV of self-report was 88% in sites with continuous access to EMRs and 61% at sites without EMRs. Kappa statistics indicated greater data agreement at sites with EMRs (0.72, 95% CI 0.56-0.88) than without EMRs (0.46, 95% CI 0.29-0.64). Adjusted for covariates, odds of data agreement were greatest in sites where EMRs were available during the entire study period (OR 4.31, 95% CI 1.67-11.13). CONCLUSIONS Primary care sites with EMRs better document mammography use than those with paper records. Patient self-report of mammography screening is more accurate at sites with EMRs. Broader access to EMRs should be implemented to improve quality of documenting mammography use. At a minimum, quality improvement efforts should confirm the accuracy of paper records with supplemental data.